pediatric case study #1 by carmen valdez and fion kung
TRANSCRIPT
PEDIATRIC CASE STUDY #1
By Carmen Valdez and Fion Kung
Scenario• Jennifer is a 13 year old female who came to the ER from a
chronic living facility and is now admitted to a med/surg floor.
• Diagnosis: Pneumonia
• Her weight is 45.2kg
• Medical history: • Chronic recurrent pneumonia• Cardiomegaly• Severe autism and developmental delay (non-verbal)• Pulmonary hypertension• Trach/PEG
Vitals upon admission
• Temperature: 97.9 axillary
• Blood pressure: 94/52
• Pulse: 70-115
• RR: 24-28
• O2: 95% on 40% oxygen via trach collar
Tests and labs
• Chest x-ray show either infiltrates vs. edema
• MRSA screen positive
• UA normal
• Lab: • WBC: 13,000 • Chemistry normal except glucose of 133
Medications• Linezolid (Zyvox) 600 mg IV q12h
• Ciprofloxacin 400 mg IV q 12h
• DuoNeb aerosols 3mL NEB q4h/ q2h PRN
• Pulmozyme 2.5 mg NEB BID
• Tobi aerosols 300 mg NEB BID
• Advair
• Solumedrol 44 mg IV q6h
• Aspirin 81 mg oral tablet daily
• Albuterol 2.5 mg/3mL NEB q4h/ q3h PRN
Orders• Pediasure 3xdaily PO/PEG and puree diet
• Bedrest
• VS every 4 hours
• Weight daily
• Repeat chest x-ray in AM
• Call MD for increased respiratory distress or oxygen demand over 50%
• Continuous pulse oximetry
• Keep oxygen sat > 92%
• Contact/Droplet precaution
Assessment in the afternoon• Blood pressure: 122/78, Temperature: 98.1 axillary, pulse: 122, RR:
30
• Coarse rhonchi and wheezing throughout her lungs
• Strong cough and purulent sputum via trach
• Regular heart rhythm and 2+ pulses x 4 extremities
• <2-3 second cap refill
• Pulse oximetry is 86%
• Sitter at bedside inform she has been coughing more and it is waking her up from her sleep
• Patient is arousable and follow some instructions
Interventions• Elevate the head of bed
• Increase oxygen to 50% as ordered by physician.
• Suction
• Continue to monitor patient for S/S of respiratory distress
• Have Ambu bag available by the bedside
• Call RT for breathing treatment
• Assess patient before and after respiratory treatment
• Keep physician updated about patient’s condition
Assessment after intervention
• O2 sat went up to 93%
• Patient still on 50% oxygen via trach
• No rhonchi present at this time.
• Patient is resting with head of the bed elevated
• Patient is not coughing at this time
• No S/S of respiratory distress at this time
Phone Call• Hello Dr. Kung, this is Carmen from medical surgical floor calling on
regards of Jennifer, a 13 year old girl admitted to ER for pneumonia.
• Today she had a episode of respiratory distress. Her O2 sats dropped from 95% to 86%. There were rhonchi and wheezing present in all lobes. She also had a strong cough and purulent sputum. Patient was arousable and able to follow some instructions.
• I increased the oxygen level from 40% to 50% as ordered, suctioned her and elevated head of the bed.
• After the intervention, I listened to her lungs and there were no rhonchi present. Her O2 sats went up to 93%.
• I contacted RT to come for breathing treatment.
Physician Order
• Ok. Good. Now I would like you to:
• Observe patient for S/S of respiratory distress
• Collect a sputum culture and let me know what the results are
• Hydrate patient with NS at 75 ml/hr
• Assess vital signs including lung sound every hour
• Call me if O2 sat drops <92% or if there is any change in vital signs
Complication
• Pleural effusion
• Empyema
• Lung abscess
• Pneumothorax
• Obstructive airway due to secretions
• Hypoperfusion
• Sepsis
Preventing complications• Monitor vital signs closely
• Assess LOC
• Assess for respiratory distress (retraction, nasal flaring, tachypnea, cyanosis)
• Assess lung sound
• Maintain hydration
• Practice good hand hygiene
• Do not smoke
• Get plenty of rest, healthy diet and moderate exercise
• Drink plenty of fluids
Consultations• RT
• Nursing manager/case manager
• MD
• Dietitian
• Social worker
• Speech therapy
Patient teaching• Assess readiness to learn
• Assess patient’s knowledge about disease
• Take all the antibiotics as ordered
• Proper hand washing
• Continue to encourage adequate fluid intake
• Encourage patient to get plenty of rest
• No smoking around patient
• Get flu shot every year
• Get pneumonia vaccine
• Call the physician if experiencing symptoms of respiratory distress
• Have patient verbalize the teaching
Appropriate Documentation • Interventions: • Suction• Increase oxygen level to 50%• Vital signs change• Update physician about vital signs change• Assessment before and after respiratory treatment• Medication administration • LOC, lung sound, heart sound changes
If it is not documented, it was never done!
References
• Cardinale, Fabio., Cappiello, R.A., Mastrototaro, M.F., Pignatelli, M., & Esposito, S. (2013). Community-acquired pneumonia in children. Early Human Development 89 (3), 49-52. http://dx.doi.org/10.1016/j.earlhumdev.2013.07.023
• Chavanet, P. (2013). The ZEPHyR study: A randomized comparison of linezolidand vancomycin for MRSA pneumonia. Médecine et maladies infectieuses 43 (2013) 451–455. http://dx.doi.org/10.1016/j.medmal.2013.09.011
• Medscape. (2014). Pediatric pneumonia treatment & management. Retrieved from http://emedicine.medscape.com/article/967822-treatment#aw2aab6b6b5